Healthcare Provider Details

I. General information

NPI: 1568081859
Provider Name (Legal Business Name): SYDNEY WYATT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 05/04/2024
Certification Date: 05/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 V ST # 1100
SACRAMENTO CA
95817-1460
US

IV. Provider business mailing address

19405 TG NATION WAY
HARRAH OK
73045-6333
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-2737
  • Fax:
Mailing address:
  • Phone: 405-395-8380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number13484
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: